Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Wednesday, December 24, 2008

Clink Responds

In my post “Who Is A Criminal?” one anonymous commenter posted a link to a newspaper story about a former musician who died of benzodiazepine withdrawal in a Cleveland jail. The anonymous commenter wondered what I thought about the story.

Over the course of the years it's not unusual for people to send me links, both on and off the blog, to stories about horrible things that have happened in a jail or prison and to ask my opinion about it. The link usually comes in an email with the subject heading, "Can you believe this???" or "Does this really happen???" The expectation seems to be that I'm supposed to either share their outrage or else defend some obviously horrible outcome.

I do neither, mainly because I don't know anything particular about the case in the media. I do know that the full story never gets reported because facility administrators and staff are bound by confidentiality (or by their attorneys) so the only information public hears about is the horrible stuff.

That being said, Anonymous Commenter followed up the comment with a few specific good questions that I'm answering here.

The Anonymous Questions are:

1. Is what happened to Sean Levert a symptom, in your view, of a tendency by prison administrators to treat psychiatric illnesses as not 'real' -- or was it an exception to the norm?

Clink responds: I can't comment on the Levert case specifically since I don't know the facts of the case. Most prison officials and correctional officers I've worked with don't have any trouble acknowledging that psychosis is a real illness. Sometimes they (and my patients) aren't always up to date regarding information about the medical nature of clinical depression and I've educated people about that.

2. The new Cuyahoga jail policy includes weaning prisoners off benzodiazepines. What's your take on this -- considering that these are relatively short-term prisoners, is it appropriate for a clink shrink to change the drug therapy? Is it appropriate for a shrink to go along with a policy designed, it would seem, less on therapeutic reasons than on convenience to the prison?

Clink responds: Correctional psychiatrists don't prescribe based on length of time in jail because we don't have any way of knowing who the short-timers are. We don't generally know trial dates, pretrial hearing dates, parole or probation hearing dates or mandatory release dates. Regarding prescribing practices, I blogged about this quite a while ago in my post "Change Is Good" so I won't be completely repetitive here. The short story is that there are valid clinical reasons to change someone's medicine that have nothing to do with cost or policy. Medication needs change depending on the environment. Someone with diabetes will need less insulin in a hospital because he'll be getting a controlled diabetic diet and won't have access to off-diet goodies. Prisoners will need less (and sometimes no) medication once they are abstinent from drugs and alcohol in a controlled environment. Sometimes the free society treatment is being provided by a non-psychiatrist and it just frankly doesn't make sense or is inadequate. There are too many hypothetical possibilities to cover them all, but those are the most common reasons why I change medications. The other thing to be aware of---and this is a bit different from free society medicine---is that you're not prescribing for an individual, you're prescribing for an institution. Anything you give to one inmate will eventually end up in the hands of another. For example, if you use tricyclic antidepressants liberally as a sleeping pill you will eventually have an institution filled with medication that is potentially lethal in overdose. Or that can be bad for someone with liver disease (and lots of my folks have hepaitits). There are valid institutional reasons for certain prescribing policies.

3. If a prisoner comes in with a current diagnosis, how much weight do you give that in determining your treatment? Do you defer to the previous doctor, or consider yourself to be starting from scratch?

Clink responds: It depends upon who gave the current diagnosis. First of all, most of my patients weren't getting treatment prior to incarceration. And for those who say they were in treatment, in the majority of cases that treatment can't be confirmed. I once scrupulously collected records for my patients for about four months, when I was new to corrections. Eventually I found that record collection was a futile activity for three reasons: 1. Most of my releases were returned with the comment 'unable to locate patient'---ie., they were never in treatment like they said they were, 2. The records gave me information I already knew from taking a history, and 3. The information I needed wasn't in the documentation because the discharge summary was dictated by a ward social worker or nurse (and only signed by the psychiatrist) and didn't contain the basis for the diagnosis. So, regarding the weight given to previous diagnosis: If I know the doctor and trust their clinical skills I give significant weight to that. If I've never heard of the person before, or if the patient is completely new to me (never seen during previous incarceration) then I start from scratch. If anything the patient tells me suggests that his clinical circumstances have changed, or if he doesn't seem to be responding to appropriate treatment, I restart from scratch. If there's something about the clinical picture that is inconsistent, I rethink the diagnosis. Clinical circumstances change over time, symptoms can change over time, new information can appear or develop so you just keep an open mind. A psychiatry professor I respect once said (on this podcast) that "A good clinician is someone who makes prudent decisions based on insufficient information". In other words, no clinician every has an entirely complete database to work from so you do the best you can with what you've got.

OK, I hope that answers the Anonymous Questioner. Those were good questions.

5 comments:

Excellent point re diagnosis with little data. Two problems I believe are endemic to "forensic" diagnosis in CA: medical records are brimming with "self-report" without any clinician's attempt to corroborate. Rarely does it caveat with "pt reports..."

Just one example: I have yet to figure out how to evaluate for head injury. If I outright ask, 7 out of 10 report an historical (M)TBI, and 3 out of 10 claim a seizure. OK, this is a "high-risk" population, but is it statistically possible? Recorded in the chart, "TBI with LOC, seizure, and coma for 3 days." Data source? Ultimately, inmate self-report. I see nothing that would suggest a cognitive or neurological deficit. The chart indicates a history of seizure meds. Data source for prescribing? Ultimately, inmate self-report. The truth? Slim and shady.

In general, the persistently mentally ill are notoriously poor reporters of history. But they don't usually purposely attempt to deceive. Ah, malingerers, the bete noir of prison psychiatry. And I must say, the benefits of taking high side-effect, potentially harmful meds from an inmate's perspective, are "understandable."

So where does this leave you? Do what's clinically prudent with the information you have and hope for the best? As I found, you are likely to have a few shots, because they'll probably be back. You have my respect, Clink. It's a very, very difficult expertise that seems to me to walk the fine line between hope and cynicism.

Great post Clink Shrink! It gave me insight I did not have previously on the special challenges that you face. It particularly had not occurred to me that what you prescribe for one inmate will fall into the hands of other prisoners. I'd think "someone" would give them the med and watch while they swallow it, but I guess there aren't resources for that.

It's only one side of the story, but this makes horrific reading.Writing for the three-judge panel of the state's 1st District Court of Appeal, Judge James A. Richman found that despite the precedent in numerous courts in other states that a jailer has a duty under tort law to protect vulnerable prisoners from attack, there was none in California, which caused the trial court to dismiss the negligence claim....Giraldo self-identifies as a "male-to-female transgender person," according to Richman's opinion. Although she was recommended, at the time she was taken into custody, for placement at the California Medical Facility or the California Men's Colony, institutions with experience in handling transsexual inmates, where they "are relatively safer... than at other state prisons," she was sent to Folsom and put into the general male population.

There, another inmate employed as a lieutenant's clerk requested that Giraldo be assigned as his cellmate, and according to Richman, "beginning almost immediately, and lasting through late January... 'sexually harassed, assaulted, raped, and threatened' plaintiff on a daily basis." Soon, she was passed along to the cell of her attacker's friend, who soon "began raping and beating her, again daily." Although Giraldo reported this abuse to prison officials and begged to be transferred to a different cell, her requests were ignored for several weeks.

She was only moved to "segregated housing" after suffering a rape and attack with a box-cutter by her cellmate in mid-March, just days after a prison counselor advised her to be "tough and strong" and discouraged her from making any further complaint. A medical officer who spoke with Giraldo two days before the rape and box-cutter attack noted the conversation in her file but took no steps to report her pleas for help to authorities, because "I don't want to get him into trouble."

Giraldo was moved to a unit for psychologically troubled inmates, but lived in constant fear that she might be sent back to the general population and placed with another abusive cellmate. She was released on parole after filing her lawsuit, shortly before the trial on her claims was to take place.

Given what happened to her, I wouldn't be surprised if she was rather more than merely "psychologically troubled".

There's also this one:"Earlier, Kevin Kallas, a psychiatrist and mental health director for Wisconsin's prisons, testified he opposed the law banning hormones.

Besides in federal prisons, hormones are given in all of the Midwestern states surveyed by the Department of Corrections, he said. Kallas called hormones a "medically necessary" treatment in some, though not all, cases.

Kallas said patients who are taken off hormones typically need counseling, drugs and hospital stays instead, suicide treatments that are more expensive than the hormones, which cost $675 to $1,600 a year. Kallas said he did not know of any other medical treatment that the state Legislature has banned in prisons."

Necessary medication is banned, even though it costs more to deal with the resultant deaths and lesser sequelae than the medication would cost.

One can always locate individual horror-stories of experiences in jail. But this appears to be a systemic problem, even in correctional facilities which are otherwise orderly, and not one confined to the USA.

December 1997. After an appearance in a Local Court, bail was refused and Ms M. was remanded in custody. Late on 22 December she was transported to a remand and reception centre where that night and into the morning of December 23 she underwent induction assessment. She was identified as transgender by the welfare officer and it was determined she should go into a “protection” wing. Having spent December 24 in court Ms M. spent December 25 and 26 in “strict protection”. During this time she was brutally raped at least twice during daylight hours. The attacks were so vicious that two other prisoners took the unusual step of reporting the incidents and giving sworn evidence. On December 27 Ms M. was found dead in her cell hanging by a shoelace.- Inquiry into a death, Coroner J Abernethy, Wednesday 21 July 1999. Ref: W308 201/99 JI-D1 (PDF).

I'm the anon, and, yes, that answers my questions. Particularly interested in the discussion of the need to take into account the dispersal of prescriptions into the general population.

And I'm surprised to learn that you wouldn't have info on a prisoner's key dates ... I'm guessing that means you don't get the records on those, but might ask the patient about them in some circumstances? I mean, my therapist and I would talk about when layoffs were coming at work, or such.

I take your point about the unreliability of the information you're given about prior treatment. It does remind me, tho, of the time I ended up in a hospital that also took in most of the general trauma cases in a city notorious for its crime. It was my impression that the doctors and nurses were so used to working with less-than-savory patients that their hardened attitude affected their treatment of everyone. For example, it took some doing to persuade them that my request for a transfer to a different room wasn't some sneaky way to get a private room, but a desire to not be in the same room with another patient who was conducting drug deals from his bed. You've probably addressed this previously: How does a clink shrink keep from developing a shell that assumes every patient is a lying jerk?

Finally, I'm sorry for the poor wording of the first question -- certainly, I knew you wouldn't be able to comment directly on this case; rather, it was a general question, which your answer did address.